What is the treatment for hypocalcemia?

Treatment of Hypocalcemia

The treatment of hypocalcemia should include calcium supplementation with calcium salts such as calcium chloride for severe cases and calcium carbonate for mild to moderate cases, along with vitamin D supplementation as needed based on the severity of hypocalcemia and underlying cause. 1, 2

Assessment and Indications for Treatment

• Treatment is indicated when serum calcium is below 8.4 mg/dL (2.10 mmol/L) with clinical symptoms including paresthesia, positive Chvostek's and Trousseau's signs, bronchospasm, laryngospasm, tetany, or seizures 2
• Hypocalcemia can be asymptomatic or present with fatigue, emotional irritability, abnormal involuntary movements, seizures, and cardiac arrhythmias (including prolongation of the QT interval) 1
• Regular investigations should include measurements of pH-corrected ionized calcium, magnesium, parathyroid hormone, and creatinine concentrations 1

Acute Symptomatic Hypocalcemia

• For severe symptomatic hypocalcemia, intravenous calcium is recommended 3, 4
• Calcium chloride is preferred over calcium gluconate in emergency situations, as 10 mL of 10% calcium chloride contains 270 mg of elemental calcium compared to only 90 mg in 10 mL of 10% calcium gluconate 1
• For IV administration:
  • Dilute calcium in 5% dextrose or normal saline prior to administration 3
  • Administer via secure intravenous line to avoid tissue necrosis 3
  • For bolus administration: Do not exceed an infusion rate of 200 mg/minute in adults or 100 mg/minute in pediatric patients 3
  • Monitor vital signs and ECG during administration 3, 5

Chronic Hypocalcemia Management

• Daily calcium and vitamin D supplementation are recommended for long-term management 1, 2
• Oral calcium supplementation with calcium carbonate is the preferred calcium salt for chronic management 2
• Total elemental calcium intake (dietary + supplements) should not exceed 2,000 mg/day 1, 2
• For patients with hypoparathyroidism or more severe hypocalcemia, active vitamin D metabolites (calcitriol, alfacalcidol) may be required 2, 6
• Magnesium supplementation is indicated for those with concurrent hypomagnesemia 1, 2

Special Considerations

Underlying Conditions

• Treatment should address the underlying cause of hypocalcemia (hypoparathyroidism, vitamin D deficiency, etc.) 7, 6
• For patients with chronic kidney disease:
  • Maintain serum calcium within the normal laboratory range, preferably toward the lower end (8.4 to 9.5 mg/dL) 1, 2
  • Monitor serum phosphorus levels to maintain calcium-phosphorus product at <55 mg²/dL² 1

Monitoring

• Measure serum calcium every 4 to 6 hours during intermittent infusions and every 1 to 4 hours during continuous infusion 3
• For chronic management, monitor calcium levels regularly, with targeted monitoring at vulnerable times (peri-operatively, perinatally, during severe illness) 1

Important Caveats

• Avoid over-correction, which can result in iatrogenic hypercalcemia, renal calculi, and renal failure 1, 2
• Hypocalcemia risk increases with biological stress (surgery, childbirth, infection) 1
• Hypocalcemia may be worsened by alcohol or carbonated beverages such as colas 1
• For patients with liver dysfunction, calcium chloride may be preferable to calcium gluconate due to decreased citrate metabolism in these patients 1
• Do not mix calcium with ceftriaxone due to risk of precipitation 3

By following this treatment approach based on severity of hypocalcemia and underlying conditions, clinicians can effectively manage both acute and chronic hypocalcemia while minimizing complications.